Question Of The Day #10

question of the day
qod10 palpitation

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient has a narrow-complex tachycardia with a regular rhythm. A narrow QRS complex is defined as a QRS interval less than 120msec. This is a normal finding. The differential diagnoses for regular narrow complex tachycardia include sinus tachycardia, atrial tachycardia, atrial flutter, and supraventricular tachycardia (“SVT”). SVTs are typically associated with narrow QRS complexes, unless there is a concurrent bundle branch block, other aberrant conduction, or the existence of electrical accessory pathways as in Wolff Parkinson White (WPW) syndrome. The heart rate of an SVT can vary from 140-280 beats/min. Intravenous Adenosine (Choice A) is a hallmark of SVT treatment, however, Adenosine is given after vagal maneuvers have been attempted and have failed. Synchronized cardioversion (Choice B) is a last-ditch effort treatment in a patient with SVT. Vagal maneuvers and medications are attempted prior to using cardioversion. However, if the patient is hypotensive, cardioversion should be employed. Intravenous Amiodarone (Choice C), beta-blockers, calcium channel blockers, or other antiarrhythmics can be used to terminate SVTs if vagal maneuvers and adenosine are not effective. Vagal maneuvers (Choice D), such as the Valsalva maneuver (“bearing down”) or carotid massage, are the initial treatment for SVTs. Correct Answer: D 

References

Burns, E. (2019, March 30). Supraventricular Tachycardia (SVT). Life in the Fast Lane. https://litfl.com/supraventricular-tachycardia-svt-ecg-library/

Nickson, C. (2019, March 24). Narrow Complex Tachycardia. Life in the Fast Lane. https://litfl.com/narrow-complex-tachycardia/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #10," in International Emergency Medicine Education Project, August 28, 2020, https://iem-student.org/2020/08/28/question-of-the-day-10/, date accessed: December 7, 2022

Acute Management of Supraventricular Tachycardias

Acute management of SVT

The term “supraventricular tachycardia (SVT)” expresses all kinds of rhythms that meet two criteria: Firstly, the atrial rate must be faster than 100 beats per minute at rest. Secondly, the mechanism must involve tissue from the His bundle or above. Mechanism-wise, atrial fibrillation resembles SVTs. However, supraventricular tachycardia traditionally represents tachycardias apart from ventricular tachycardias (VTs) and atrial fibrillation (1,2).

Supraventricular tachycardias are frequent in the ED!

The SVT prevalence is 2.25 per 1000 persons. Women and adults older than 65 years have a higher risk of developing SVT! SVT-related symptoms include palpitations, fatigue, lightheadedness, chest discomfort, dyspnea, and altered consciousness.

How to manage supraventricular tachycardia?

In clinical practice, SVTs are likely to present as narrow regular complex tachycardias. Concomitant abduction abnormalities may cause SVTs to manifest as wide complex tachycardias or irregular rhythms. However, 80% of wide complex tachycardias are VTs. Most importantly, SVT drugs may be harmful to patients with VTs. Therefore, wide complex tachycardias should be treated as VT until proven otherwise (1,2).

The chart below summarizes acute management of regular narrow complex tachycardias:

Acute Management of Regular Narrow Tachycardias

References and Further Reading

  1. Brugada, J., Katritsis, D. G., Arbelo, E., Arribas, F., Bax, J. J., Blomström-Lundqvist, C., … & Gomez-Doblas, J. J. (2019). 2019 ESC Guidelines for the management of patients with supraventricular tachycardia: the Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). European Heart Journal, 00, 1-66.
  2. Page, R. L., Joglar, J. A., Caldwell, M. A., Calkins, H., Conti, J. B., Deal, B. J., … & Indik, J. H. (2016). 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology67(13), e27-e115.